Inadequate Nurse Aide Staffing Levels
Penalty
Summary
The facility failed to meet the required nurse aide to resident ratios across multiple shifts, as evidenced by a review of staffing records and staff interviews. Specifically, the facility did not provide the minimum number of nurse aides needed for the day, evening, and night shifts on 14 out of 21 reviewed shifts. For instance, on January 7, 2025, the day shift had 8.00 nurse aides instead of the required 8.90 for a census of 89 residents, and the night shift had 4.69 nurse aides instead of the required 5.93. Similar deficiencies were noted on subsequent days, with the facility consistently falling short of the required staffing levels. The report highlights specific instances where the facility's staffing levels were inadequate, such as on January 10, 2025, when the day shift had 7.77 nurse aides instead of the required 9.00 for a census of 90 residents. Additionally, on the same day, the night shift had only 4.30 nurse aides, falling short of the required 6.00. The facility did not have additional higher-level staff available to compensate for these deficiencies, indicating a systemic issue in maintaining adequate staffing levels to meet regulatory requirements.
Plan Of Correction
Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of federal and state law. This statement applies to all observations listed below. The facility is unable to retroactively correct the cited issue. Staffing meetings will be held 5 days a week with the scheduler, Director of Nursing and Nursing Home Administrator, to review the current day CNA staffing ratios and upcoming days of the week and following week to ensure appropriate staffing levels for CNA staffing ratios for each shift. The facility is focusing on retention of existing nurse aides and recruitment of new nurse aides through the efforts of the Human Resources manager and the Administrator working on facility recruitment and retention plan to maintain required state ratios. If the projected staffing ratios do not meet minimum, then the facility will reach out to current staff and staffing agency using as needed bonuses to enlist staff or agency staff to meet the minimum requirement. The facility will continue to recruit staff through all platforms. Daily audits of the schedules will be conducted for 7 days and weekly for 2 weeks. The results will be reviewed at Quality Assurance and Performance Improvement meetings until substantial compliance of the state ratio can be met through the hiring and retention plan over the next 90 days.